4 A-pg. 1 Process Code W1.1 Division of State Agency Services Bureau of State Risk Process Sub-Process Worker's Compensation Claims Basic All Claims Input Process Output Responsibility Basic All Claims (W1.1) Claims received 1. Claims are either entered into STARS by an agency s Worker s Compensation Coordinator using STARSWeb or sent to DOA by FAX, mail, or . (A claim consists of an employee s First Report of Injury Disease, (WKC12) completed by the injured employee s supervisor.) After receiving a claim from an agency, the Risk Specialist searches STARS by claimant name and or/ Social Security Number to determine if the claim has been entered onto the STARS system. If the claim has not been entered into STARS, the Risk Specialist enters it. Determine if the claim information is complete 2. After finding the claim or entering the claim into STARS, the Risk Specialist must determine if the information entered is complete, accurate, and ready to be distributed to the proper claims adjuster. Obtain needed information 3. If the information is not accurate, the Risk Specialist will obtain the needed information by either consulting coding documents, contacting the agency s Worker s Compensation Coordinator, and/or consulting the Bureau s Worker s Compensation staff. Set up claim folder 4. The Risk Specialist sets up a claim folder and puts it in the IN box of the proper claims adjuster. Legend: System Process or Report Manual operation/ process Decision Stored data Start/End Off-Page On-Page Last Modified: 12/18/2002 at 9:25:16 AM S:\DSAS\BSRM\Internet Updates\WC Claims Mgmt.vsd Page 4 of 57

7 Medical Only Claims (W1.2) Determine if the claim is compensable 1. A Risk claims representative receives a new claim from the Risk Assistant. The claims representative reviews the claim to determine compensability, the claim must arise out of employment, occur in the course of employment, and are causally related to the employment. 1a. If the claim is compensable go to step 2 1b. If the claim is not compensable, the claims representative sends a denial of compensability letter to the claimant, carbon the employer, the Department of Workforce Development, and the claim file. The claims representative will set a diary to review the claim for closure. Monitoring claim activity 2. Upon determining compensability the claims representative will set a diary to review the claim for closure in 90 days if there is no activity. Activity is usually the receipt of medical bills and treatment notes. The claims representative will review the treatment notes to ensure the bills that are being paid are related to the date of injury. Also, the claims representative will monitor the treatment to ensure treatment is reasonable and necessary for the current injury. If reasonability and necessity is in question the claims representative may choose to refer the claim to case management vendor or for an Independent Medical Evaluation for a second opinion on necessity of treatment. If a bill is received for treatment that is clearly unrelated to the current injury a denial letter is sent tot he medical provider. Bills that are related to the current injury should be paid according to process W1.5.

8 When to close claim 3. The claims representative will continually be reviewing medical records to monitor for an end of healing status. If end of healing has been reached the claim should be closed. If end of healing has not been reached Step 2 should continue to be followed. Application for Hearing 4. If an application for hearing is received, the claim should be given to the claims supervisor, who in turn will give it to a claims examiner for continued handling.

12 Lost Time Claims (W1.3) Determine if claim is compensable 1. Once an agency forwards an initial lost time WKC-12 to DOA, a Risk claims examiner will receive this lost time claim in one of two ways, either from the Risk Assistant or from a claims representative. The claims examiner will review the claim to determine compensability. A useful tool when determining compensability is the Three-point-contact. This is contact with the injured employee, employer and doctor (or representative, e.g., nurse). This should be done within 24 hours of receipt of the claim. A step by step procedure for the Threepoint contact can be found in the Workers Compensation Manual. To be compensable the claim must arise out of employment, occur in the course of employment and be causally related to the employment. 1a. If the claim is compensable the claims examiner will send the WKC-12, First report of injury (attached), WKC-13a (attached) to DWD within fourteen days of the date of loss. Go to step 2. 1b. If the claim is not compensable, the claims examiner sends a denial of compensability letter to the claimant, carbon the employer, the Department of Workforce Development, and the claim file. Also, a WKC-12, First report of injury, along with a WKC-13 and WKC-13a, must be sent to DWD indicating that we are denying the claim. The claims examiner will set a diary to review the claim for closure. 1c. If the claim needs to be suspended to investigate further the compensability, the claims examiner will send the WKC-12, First report of injury, WKC-13, and WKC-13a to DWD with rationale for investigation within fourteen days of the date of loss.

14 Monitoring Medical Treatment 2. The claims examiner will obtain and review medical treatment information and keep in close contact with the injured employee and the employer to assure that all possible return to work efforts are being utilized. See process W1.8 for further return to work information. Also, it is necessary to monitor medical treatment to make sure that all treatment is reasonable and necessary. The claims examiner will forward and authorization and medical provider list tot he claimant for signatures. When the claims examiner receives this back all past medical records will be requested and reviewed. When reviewing medical treatment the determination of whether or not to use claims management services must be made. See process W1.6 for further information on claims management services. Determine if medical treatment is related to the work injury 3. The claims examiner will carefully review all medical bills and treatment notes to be sure that the provider is only billing us for treatment that is relevant to the work injury. If the bill is related to the work injury then the bill should be paid using process W1.5, Bill Payment. If the bill is not related to the work injury or if the claim has not been accepted yet, a denial or suspension letter is sent to the medical provider. Disability payments 4. The claims examiner will receive a WKC-13 and WKC-13A from the agency. After reviewing these forms for completeness and accuracy disability (indemnity) payments must be made to the employee as long as they remain off work. This payment is made from calculations on the DOA-6026 (attached). This is done using process W1.5, Bill Payment.

15 Determine if medical treatment has been completed 5. If medical treatment has not been completed return to step 2 and continue the process again. If medical treatment has been completed obtain a final medical report (WKC-16, attached) and send it to DWD along with the final WKC-13. If the treating MD assigns Permanent Partial Disability (PPD), the examiner must calculate the rating into benefits and pay as accrued. The pay in accordance to the state PPD rate. Upon payment of the final PPD and updated WKC-13 should be submitted to DWD and the file is closed. If no PPD is assigned, the claim can be closed when medical treatment has been completed.

19 Hazardous Duty Claims (W1.4) A hazardous duty claim is a claim where the injury occurs to a protected class employee in the line of duty. Hazardous duty claims are handled in the same manner as Lost Time Claims (W1.3) with one exception. The claimant receives benefits, which means the employee gets paid their full wage instead of two-thirds paid under workers compensation benefits. The employing agency determines if the claimant receives the benefits and handles all aspects of indemnity. Workers compensation only deals with the medical aspect of the claim.

21 Bill Payment (W1.5) Determine if bill should be paid under Worker's Compensation Benefits 1. When a medical bill is received the claims adjuster determines if the bill should be paid under worker s compensation benefits. If the bill is not covered under worker s compensation benefits the claims adjuster will send a denial of payment letter to the provider, carbon the employer. If the bill is covered under worker s compensation benefits the claims adjuster must determine whether to pay the bill internally or externally. Determine if bill should be paid internally or externally 2. Bills that are always sent to the Audit Company include outpatient medical provider, chiropractor, physical therapy, hospital outpatient, and hospital inpatient. Bills that should not be sent to the Audit Company include ambulance charges, anesthesia, medical supplies, outpatient emergency room, work hardening, pharmacy charges, mileage, telephonic case management, all indemnity, and all expense charges. External bill payment 3. Bills that are paid externally are sent to the billing Audit Company to possibly receive a rate reduction. Bills that should be paid externally should be placed in the Audit Company out folder. The Risk Specialist picks up these bills daily and mails them to the Audit Company. Audit Company upload to the STARS system 4. The Audit Company sends a weekly file containing all bills they have processed via the File Transfer Protocol site for uploading onto the STARS system. A worker s compensation claims representative uploads the file, which posts each payment made by the Audit Company to the proper claim in STARS. Procedures for this can be found on the G drive: G:\Riskmgmt\STAR\Corvel\CorvelUpdateProcedure.doc

22 Internal Bill Payment 5. When paying bills internally use the STARS system. Refer to the STARS manual for instructions as show below. MAKING A PAYMENT The check writing module is not within the claim. This gives you the option of h or processing all of your payments at the same time. Begin by creating the invoic then pay the bill(s) from the invoice you created. Be sure to indicate the status o claim on each payment. To Create the Invoice: Click on More from the left toolbar or Click on Go from the top toolbar. Click on Checks module Click on Check Register/Check Printing button on the tool bar (only one or other appears on the screen. You are in the one that is not appearing.) Click on New Click on Payee Name Rolodex button to search for payee (If payee is a comp check the box beside the payee name field to specify it is a company. Tab past Vendor Id - Auto filled by the payee tax ID number Tab past Tax ID Auto filled with the address line of the payee Tab past Invoice # - Auto generated field for tracking. Do not edit this field Tab past Account # - Leave this blank Tab past Check Status Auto filled Enter Invoice Date Today s date Tab past Check Number leave blank Enter short description in Memo This field does not carry over to the claim transaction screen. Enter Adjuster by using the Rolodex search button to locate your adjuster Enter Invoice total Total of the complete invoice Tab past Transaction Leave blank Tab past Balance Leave blank Enter Due Date Date you want WiSMART to release the check. If left blank automatically is filled and released from WiSMART the day after you print you proof report. Tab past Check Date leave blank Click on Save If you get a red bar error across the bottom of the screen it means the Invoice alr exists. This will only happen if two people click on creating an invoice at the sam time. Do not save the invoice. Close the invoice and re-enter a new invoice.

23 Create the Payment Click on Transaction tab of the invoice screen Click on New This opens search screen Enter search criteria to locate the claim Highlight the claim you are attaching payment to Click Ok Click on the Financial Bucket Payment Type Click on Status - Indicate if the claim is open or closed Select Transaction Code from the drop down table of payment types Transaction Date Auto generated with the date payment is entered. Enter the Service From Date of 1 st service Enter the Service to Date of last service Enter Paid Amount Amount of bill you are paying Click on Additional Info Tab Enter Single Check and use drop down to select how the check should be ba in WiSMART (Default is No ) No indicates all invoices to the same vendor will be printed on one check at WiSMART. Yes indicates you do not want this invoice combined with other checks to th same provider. Enter Mail Code by using the drop down to select how you want the check mailed. KL indicates the check should be mailed directly out in central mail 2L indicates the check should be returned to you for mailing. Enter Check Stock use drop down to select your agency code Tab past Sent to WiSMART Leave this field blank auto populated when y print your proof report Tab past Corvel Control # this field is only updated with Corvel payments Notes Reference Number - is required to be filled in when making multiple payments single invoice. If not completed, WiSMART will not recognize multiple lines to pr the EOB portion of the check. If your invoice has multiple payments, save the invoice then create the payments continue doing this until the invoice is paid in full. Make sure to mark single ch flag on each of the payments. Fill in the Reference Number field on each. Make sure you have a $0 Balance on the Invoice screen after you are done with e invoice. Make sure to mark status as Final when making payments on closed files; othe the file will be re-opened Corvel payments will never increase a reserve on open or closed claims.

25 Claims Services (W1.6) Claims services consists of Telephonic Case management (TCM), Medical Case (MCM), Loss of Earning Capacity Evaluations (LOEC), Independent Medical Evaluations (IME), and Claims Investigations. Contracted vendors provide these services. Determining when to order claims management services 1. When handling a claim, a determination must be made as to whether or not services are required to manage a claim efficiently. Consulting a list of criterion for using each service makes this determination. Use Telephonic Case (TCM) if/when The provider renders a vague diagnosis Treatment is excessive (generally continuing beyond 6-8 weeks.) There is a lapse in treatment You see more than 3-4 modalities in one treatment plan Repeat diagnostics are scheduled There are re-injuries or multiple injuries (If the claimant has several injuries, some of which may be non-work related.) Duplicate charges Chiropractor treating an unusual injury Unknown chiropractor Unlimited treatment plans (no end in sight). Care beyond 6 months Treatment plan suggesting future care long in duration Patient has a history of chiropractic treatment Treatment is for pre-existing condition Failure of the provider to respond to your request for records Provider known to over-treat Assistance is desired for intervention or explanation of treatment, including area such as diagnostic, surgery, hospitalization, or out of the ordinary conditions.

26 Use Medical Case (MCM) if/when A claimant has numerous prior claims. The injury is serious. Treatment appears to be excessive. The treating physician is not cooperating with the adjuster. Claimant has significant underlying problems. Obtain an Independent Medical Evaluation (IME) to: Physical Illness: Determine if the condition diagnosed is causally related to the work injury. Determine if treatment is reasonable and necessary (ex-surgical procedures, pain clinics). Determine temporary or permanent work restrictions (determining return to work date). Determine a Permanent Partial Disability (PPD) rating. Determine End of Healing (EOH). Distinguish between a pre-existing condition. Mental Illness Determine if there are enough criteria for meeting psychological diagnosis for DCM-IV (e.g., PTSD). Determine if there is extraordinary stress per School District No. 1 vs. ILHR. Obtain a Loss of Earning Capacity Evaluation (LOEC) if/when: Attorney names a vocational expert. Claimant has an unscheduled injury and can not return to the same job. Claimant s physician contends claimant has permanent total disability.

27 Use Claims Investigations if/when: There is an identifiable or anonymous tip that the employee may be exaggerating the injury and able to perform beyond capabilities identified by the treating physician. There is the indication the employee is working at another job even though medically excused from work. Examples: employee is never home, doesn t return phone calls, or doesn t answer correspondence. The employment includes work that exceeds medical restrictions. s the employee was earning wages while collecting indemnity payments at the same time. An Independent Medical Exam (IME) or attending physician s report indicates few objective findings to support the disability. The employee s complaints far outweigh the objective medical findings. The Claimant appears to be exaggerating or falsifying information. ***Please be aware that the above criteria are simply guidelines. Claims experience intuition and common sense will be the most valuable guide when assessing treatment and the need for claims management services. Referrals to Vendors 1. Upon determining if claims management services are needed, the claims adjuster will refer the claim to the proper vendor. A list of vendors can be obtained from the Worker s Compensation Manager or the Claims Supervisor. For all of the above claims management services, permission from the Claims Supervisor is not needed with the exception of surveillance when used for Claims Investigations. To obtain surveillance services the claims adjuster MUST consult with the Claims Supervisor. When referring a claim to a vendor always send a WKC-12, First Report of Injury, along with other documentation specific to the service. For TCM and MCM include medical records and treatment notes. Setting up IME is much more involved: you must select a physician and arrange the appointment; see the section on IME s in the Worker's Compensation Manual which can be viewed on the World Wide Web.

28 Reports from Vendors 1. The vendor will send the claims adjuster a report providing the information requested. Sometimes there will be several reports until the file is closed with the vendor. The claims adjuster will review this information and keep the file updated. Invoices from Vendors 2. Invoices will be received from the vendor via or mail for services rendered. The claims adjuster reviews the invoice for accuracy and appropriate charges. If there is an error the invoice should be forwarded with a note to the Worker's Compensation Manager (WCM). The WCM will contact the vendor for corrections and/or send a disputed charges notice. For MCM, TCM, LOEC, and IME s the claims adjuster pays the invoice using STARS following the Bill Payment process (W1.5). Send one copy of the paid invoice for TCM, MCM, and LOEC to the WCM. This copy is filed in case of dispute from the vendor in the future. Within five days of receipt Claims Investigations and Transcription invoices are forwarded to the WCM with 2 copies attached. The WCM sends the original and a copy to DOA Accounting for disbursement of funds. Again a copy is filed in case of dispute from the vendor in the future.

30 Reserving (W1.7) Case Reserves are establishes separately for indemnity, medical and expense values. The case reserve represents the best current estimate of probable or expected settlement cost associated with a claim. The cost does not include amounts that have already been paid. Medical case reserve is that part of a case value associated with curative and/or therapeutic medical costs necessary to treat employmentrelated injuries or disease. Indemnity case reserve is that part of a case value associated with statutory benefits as follows: Permanent Total Disability Permanent Partial Disability Temporary Total Disability Temporary Partial Disability Fatalities Retraining (Occupational Vocational rehabilitation Services) Expense case reserve is that part of a case value associated with claim and litigation management such as legal expenses, independent adjuster/experts, special investigation reports, independent medical examinations, medical bill audits, copy charges, and case management services. Expense reserves do not include general claim management expenses not specifically allocated to individual claims. Evaluate Initial Claims info 1. First aid claims will not carry a medical case reserve. These claims either do not involve medical treatment by a medical provider or the medical treatment is limited to a one-time visit to a medical provider. Medical-only claims will carry a standard or formula medical case reserve of $ and a standard expense case reserve of$20.oo, however reserves can increase if treatment continues for an extended period of time.

31 Indemnity claims will carry case reserves that properly and adequately reflect statutory wage loss or restraining values in addition to medical and expense claim values. Complete Reserve Worksheet 1. To get a more accurate reserve value after the initial review and receiving medical notes the claims adjuster will fill out the reserve worksheet, using the initial reserve guidelines shown on the next three pages:

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